Friary House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

The service was previously in breach ofthe legal regulationin relation to good governance. Improvements were found at this assessment, however the service remained in breach of this regulation.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had an ethos where, should people’s needs change, they could continue to receive care at Friary House, assuming their needs could still be met there.
The registered manager, when asked about the vision and values of the service said, “Promote independence, and help them continue to live their life.” They went on to say they, as a provider, ensured people continued to maintain skills, for example, if they could still wash their face and hands, they would be encouraged to do this, and staff would only assist with what was needed.

There was a close knit and long-term team providing care at Friary House who worked together towards a common goal of providing safe, quality care.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

We received positive feedback about the management team. Staff felt supported by them. A staff member said, “The [registered] manager has an open-door policy and is always makes themselfavailable to us all.They are easy to talk to and a people person.” A relative told us, “[Registered manager] was very transparent about the negative CQC report last year and mentioned it straight away and advised that I look at it. I am grateful they took that action, but we have never had any problems at all.” A healthcare professional told us, “The leadership team is approachable, confident and very competent and they work well with the medical team.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

A staff survey had very positive outcomes. Staff who responded all felt supported and that the management team were approachable. This was echoed by feedback from people and their relatives.

There was a ‘Speaking up – Whistleblowing’ policy in place. This formalised the providers commitment to protecting whistle-blowers from possible harassment and acting on information of concern raised with them. All staff feedback showed they would approach the management team should they need to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had an equality and diversity policy that detailed how they would maintain people and staff rights and would ensure equality and equity.

The registered manager told us they had a diverse staff team that included overseas staff. They all worked well as a team and equality was good in the service. All care staff worked as a team as there were no senior staff, the registered manager told us they believed this made staff feel valued.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

When we inspected, audits were being completed and the registered manager and provider had some oversight of the service. This was much improved since our last assessment; however, audits needed to be embedded into the practice of the service and used more effectively in driving improvements. We found gaps in summaries in some audits and there appeared to be no analysis to show if there were themes or trends, for example in the deaths that had happened. No information such as whether the death was expected or unexpected was recorded, or if there was to be an investigation or the Coroner involved. Oversight of the service required further improvements. This meant oversight of deaths was not complete and important events such as Coroner inquests may be overlooked.
Other areas where oversight was lacking included staff recruitment records, there remained gaps in employment histories an area needing improvement identified at our previous inspection. Ongoing concerns about the quality of MCA assessments and best interest decisions had not been noted by the management team, nor had the ongoing medicines shortfalls.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We received positive feedback from 2 healthcare professionals about Friary House. One told us, “They are very good at picking up on things early when something is not quite right… They all know their residents well.” The other told us, “Whenever visiting Friary House, whether in person or via video call, residents always appear well presented and well cared for. Interactions between staff and residents are very good and it is clear they genuinely care about their residents and do everything possible to maintain their wellbeing… Medical advice is followed appropriately and promptly. The leadership team is approachable, confident and very competent and they work well with the medical team.”

The provider made links with community partners and ensured people received a seamless service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Audits were not yet embedded into the day-to-day running of the service and did not always contain sufficient analysis of events to be of use in providing oversight and learning about the service. This meant opportunities for improvement may be missed.
Information about events such as accidents was reviewed and shared with the staff team during handover meetings.